Topical composition for use in the treatment of inflammatory bowel disease

ABSTRACT

The present invention relates to a topical composition containing a probiotic and hyaluronic acid or a pharmaceutically acceptable salt thereof, for use in the treatment and/or prevention of inflammatory bowel disease.

The present invention relates to a topical composition containing a probiotic and hyaluronic acid or a pharmaceutically acceptable salt thereof, for use in the treatment and/or prevention of inflammatory bowel disease.

STATE OF THE ART

Inflammatory bowel disease (“IBD”) is characterized by chronic inflammation of the intestinal wall and includes inter alia Crohn's disease and ulcerative colitis. Conventional therapies are represented mainly by: 5-aminosalicylic acid (5-ASA), corticosteroids, azathioprine/6-mercaptopurine, methotrexate, cyclosporine, and anti-TNFa agents, which are mainly intended to modulate the immune system [1].

These diseases are “idiopathic” diseases, i.e. with unknown cause. The predominant pathogenetic hypothesis is that of an abnormal intestine immunological reaction against antigens (for example, bacteria normally present in the intestine). This immunological imbalance can be established due to an altered interaction between genetic factors of the individual and the environmental factors.

On the other hand, probiotics, defined as “live microorganisms which when administered in adequate amounts confer a health benefit on the host” [2] could modulate in a positive way the human microbiota, i.e. the set of symbiotic microorganisms which are found in the digestive tract, allowing to increase the commensal bacteria at the expense of the pathogen ones present in greater quantities in patients with IBD.

Their mechanism of action is not yet clear, but it can be assumed that probiotics modulate the intestinal permeability and the mucosal immune system, keeping the pathogenic bacteria away from the surface of the intestinal mucosa [1, 3].

Several strains were used in IBD and a number of publications attest their efficacy [4].

However, to date only few clinical studies have been published relating to the administration of probiotics in the form of a rectal preparation, and only in combination with conventional therapies [5-8].

In particular, the publication Dig. Dis. Sci. 2011, 56:1 178-1 187 [5] demonstrated that the administration of 5-ASA orally alone or together with Lactobacillus casei DG orally has no significant effect on the gut flora, unlike the combined administration of 5-ASA orally and of said Lactobacillus rectally.

This work highlighted a significant topical and anti-inflammatory activity of the probiotic, when used in conjunction with conventional therapies.

A possible mechanism of action of the association 5-ASA and Lactobacillus casei DG rectally may be related to alterations in the microbial flora that adheres to the mucosa, thus contributing to the manipulation of the mucosal immune response and changing the balance of pro-inflammatory cytokines in favor of the anti-inflammatory ones.

However, the above clinical trials do not discuss the fundamental aspect of the “mucosal healing” in the treatment of inflammatory bowel diseases, that is the complete absence of any inflammatory and ulcerative lesions. In clinical practice, the “mucosal healing” is associated with long term symptomatic remission, and a longer interval without recurrence. This results in a reduction in the frequency of hospitalizations, complications and surgical resections, with a significant improvement of the quality of life of the patient [9, 10]. Hyaluronic acid, a glycosaminoglycan, is known to play an important role in ensuring the hydration of the tissues, at the same time protecting them from excessive stresses and strains [11-13].

By stimulating the formation of collagen and connective tissue, hyaluronic acid protects the body from viruses and bacteria, increases the plasticity of tissues and ensures optimal skin hydration [11, 14].

In the absence of formulations capable of dealing with both the treatment of inflammatory bowel diseases and the appearance of the “mucosal healing”, the need for an alternative formulation to respond effectively to these challenges is therefore felt.

DESCRIPTION

h has now surprisingly been found that a topical composition containing a probiotic and hyaluronic acid is particularly advantageous in the treatment of inflammatory bowel disease. In particular, in the abovementioned composition, the probiotic and hyaluronic acid show a surprising synergistic effect in the treatment of the abovementioned disease. Therefore, the object of the present invention is a topical composition containing a probiotic and hyaluronic acid or a pharmaceutically acceptable salt thereof, and preferably at least one physiologically acceptable excipient, for use in the treatment of inflammatory bowel disease, such as Crohn's disease and ulcerative colitis.

A probiotic according to the invention is selected from Lactobacillus acidophilus, Lactobacillus brevis, Lactobacillus buchneri, Lactobacillus casei, Lactobacillus paracasei, Lactobacillus catenaforme, Lactobacillus cellobiosus, Lactobacillus crispatus, Lactobacillus curvatus, Lactobacillus delbrueckii, Lactobacillus fermentum, Lactobacillus jensenii, Lactobacillus leichmannii, Lactobacillus minutus, Lactobacillus plantamm, Lactobacillus reuteri, Lactobacillus rogosae, Lactobacillus salivarius, Bifidobacterium adolescentis, Bifidobacterium angulatum, Bifidobacterium bifidum, Bifidobacterium breve, Bifidobacterium catenulatum, Bifidobacterium dentium, Bifidobacterium eriksomi, Bifidobacterium infants, Bifidobacterium longum. Bifidobacterium plantamm, Bifidobacterium pseudocatenulatum, Bifidobacterium pseudolongum, Streptococcus lactis, Streptococcus rajfinolactis, Streptococcus thermophilus, or a mixture thereof.

Preferably, the probiotic is a Lactobacillus, more preferably is Lactobacillus casei, even more preferably is Lactobacillus casei DG (strain deposited at the Pasteur Institute in Paris with the deposit number I-1572CNCM).

Hyaluronic acid or a pharmaceutically acceptable salt thereof according to the invention is a high molecular weight hyaluronic acid, it preferably has a molecular weight comprised between 500,000 and 3,000,000 dalton, more preferably greater than or equal to 1,000,000 dalton.

Physiologically acceptable excipients according to the present invention are those known to the expert in the field, as described in the Handbook of Pharmaceutical Excipients, sixth edition 2009, incorporated herein by reference.

Examples of particularly preferred excipients according to the present invention include, but are not limited to, diluents, binders, surfactants, gelling agents, stabilizers.

A particularly preferred excipient according to the present invention is xanthan gum.

According to the invention, the composition contains an amount of living probiotic cells of between 200 million and 10 billion, preferably between 500 million and 2 billion.

According to one embodiment of the invention, the composition contains an amount of living probiotic cells comprised between 0.1 and 3% by weight, preferably less than 1% by weight, with respect to the total weight of the composition.

According to the invention, the composition contains an amount of hyaluronic acid or a pharmaceutically acceptable salt thereof comprised between 10 mg and 300 mg, preferably between 50 mg and 150 mg.

According to one embodiment of the invention, the composition contains an amount of hyaluronic acid or a pharmaceutically acceptable salt thereof comprised between 3 and 15% by weight, preferably of about 5% by weight, with respect to the total weight of the composition.

According to a particularly preferred embodiment of the invention, the composition contains an amount of living probiotic cells of between 0.1 and 3%, and an amount of hyaluronic acid of between 3 and 15% of the total weight of the composition.

According to the present invention, the composition may be administered orally or rectally, preferably it is administered rectally.

The composition of the present invention acts mainly at a topical level, i.e. it does not enter the circulatory system but exerts its action only at a local level through a combination of bacterial load reduction at the application site, and repair of the intestinal mucosa.

In fact, the probiotic and hyaluronic acid act in synergy on the inflammatory process at the intestinal level, reducing the pro-inflammatory factors and increasing the anti-inflammatory ones.

The probiotic modulates, directly or indirectly, the so-called “gut microbiota”, exerting an important action on the intestinal permeability and the mucosal immune system; in this way, it allows to keep the potentially pathogenic bacteria, responsible for an excessive immune and inflammatory response, away from the surface of the intestinal mucosa.

Hyaluronic acid is, however, a compound with significant cicatricial and anti-inflammatory properties, by means of a direct action on TLR (Toll-Like Receptors). Furthermore, by stimulating the formation of collagen and connective tissue, it protects the body from viruses and bacteria, increases the plasticity of tissues and ensures optimal hydration of the skin. This protective action allows to preserve the integrity of the intestinal mucosa and to promote the so-called “mucosal healing”.

When administered rectally, the composition of the invention can be formulated in semi-solid or liquid form, preferably as a cream, ointment, pomade, solution, suspension, powder to disperse in water or gel; more preferably, the composition is formulated as powder to disperse in water.

The previously mentioned components and excipients, preferably xanthan gum, used in the composition of the invention, provide a greater consistency and a higher viscosity to the preparation, necessary to ensure that the product may remain in situ for a longer time.

According to a preferred embodiment, the composition of the invention is administered in the form of an enema or a rectal foam, preferably in the form of an enema.

Therefore, thanks to the synergic effect of the probiotic and hyaluronic acid, the composition of the invention acts directly on the ongoing inflammatory process, by significantly stimulating the production of collagen and connective tissue, resulting in the repair of the intestinal mucosa injured by the onset of inflammatory bowel disease.

Furthermore, the composition of the invention is able to play an important immunomodulatory role in the modification of the composition of the human microbiota, by increasing the commensal species and reducing the presence of potentially pathogenic species.

According to an embodiment of the present invention, the composition may be administered alone or in combination with a traditional inflammatory bowel disease therapeutic agent selected from 5-ASA, corticosteroids, azathioprine/6-mercaptopurine, methotrexate, cyclosporine, and anti-TNFa agents.

Preferably, the composition is administered rectally, one or more times per day, more preferably twice a day.

The composition of the invention is administered for a period of treatment comprised between 2 and 16 weeks, preferably for a period comprised between 4 and 12 weeks, even more preferably for a period of at least 8 weeks.

According to a further embodiment of the present invention, the composition is administered as a combined preparation with one of the abovementioned conventional therapeutic agents, for simultaneous, separate or sequential use.

A further object of the present invention is the composition containing a probiotic and hyaluronic acid or a pharmaceutically acceptable salt thereof, and preferably at least one physiologically acceptable excipient, for use in the prevention of acute radiation proctitis. Such use is particularly directed to patients undergoing radiation therapy for prostate cancer.

Experimental Part

The object of the present invention is a topical composition containing a probiotic and hyaluronic acid or a pharmaceutically acceptable salt thereof, and preferably, at least one physiologically acceptable excipient.

This formulation will be the object of a clinical study aimed to verify its effectiveness in the treatment of inflammatory bowel disease, such as Crohn's disease and ulcerative colitis. The following table summarizes the qualitative and quantitative composition of the above invention:

RAW MATERIAL mg/sachet % Sorbitol 1825 83 Xanthan gum 250 11.5 Sodium hyaluronate 100 4.5 Lactobacillus casei DG 5 1

Before achieving such a formulation, some tests were carried out with the aim of obtaining a product with the most appropriate composition for the treatment of inflammatory bowel disease, and with chemical-physical characteristics optimal for a rectal preparation. Some possible modifications in the formulation of the composition object of this invention are reported below.

Considering that the final solution, which is to be administered rectally, must be an isosmotic solution, it is necessary to modify in an appropriate manner the qualitative and quantitative composition of the thixotropic agents. In this respect, it is important to consider that also the hyaluronic acid possess a viscosifying power of, and it is, therefore, necessary to dose in an appropriate manner the quantities of excipients which have a similar power.

The amount of hyaluronic acid may be increased up to a quantity equal to about 200-300 mg, corresponding to about 9-14% with respect to the total weight of the composition, thereby reducing the xanthan gum, in order to avoid too viscous formulations which would lead to the possible formation of lumps.

Otherwise, the percentage of hyaluronic acid may be left unchanged and the amount of xanthan gum increased by about 0.5-6%.

The xanthan gum may also optionally be replaced by another viscosifying agent, such as hydroxypropylmethylcellulose (HPMC), which has a viscosity power greater than xanthan gum. Such an excipient, however, having also a greater tendency to form lumps, could be increased only up to a 3-4%, compared to what was instead done with xanthan gum.

Finally, the amount of living lactobacilli cells could be increased even up to about 10 billion, corresponding to approximately 2% of the total weight of the composition (or, taking into account the excess of living cells which is normally employed, up to a maximum of 9%), without minimally perturbing the final composition, especially in terms of viscosity As a result, the following compositions may be obtained:

RAW MATERIAL mg/sachet % Sorbitol 1826 83 Xanthan gum 252 12 Sodium hyaluronate 100 4.5 Lactobacillus casei DG 5 (1 billion) 0.5

RAW MATERIAL rag/sachet % Sorbitol 1716 78 Xanthan gum 374 17 Sodium hyaluronate 100 4.5 Lactobacillus casei DG 5 (1 billion) 0.5

RAW MATERIAL mg/sachet % Sorbitol 1683 76.5 Xanthan gum 200 9 Sodium hyaluronate 300 14 Lactobacillus casei DG 5 (1 billion) 0.5

RAW MATERIAL mg/sachet % Sorbitol 1892 86 HPMC 200 9 Sodium hyaluronate 100 4.5 Lactobacillus casei DG 5 (1 billion) 0.5

RAW MATERIAL mo/sachet % Sorbitol 1727 78.5 HPMC 155 7 Sodium hyaluronate 300 14 Lactobacillus casei DG 5 (1 billion) 0.5

RAW MATERIAL mg/sachet % Sorbitol 1826 83 HPMC 260 12 Sodium hyaluronate 100 4.5 Lactobacillus casei DG 5 (1 billion) 0.5

RAW MATERIAL Mg/Bst % Sorbitol 1650 75 Xanthan gum 200 9 Sodium hyaluronate 300 14 Lactobacillus casei DG 50 (10 billion) 2

These are only formulation examples aimed at showing the possible combinations of the various components of the above composition.

REFERENCES

-   1 Scaldaferri F. et al. “Gut microbial flora, prebiotics and     probiotics in IBD: their current usage and utility”, BioMed Research     International 2013, 9 pages. -   2. Food and Agriculture Organization. Health and nutritional     properties of probiotics in food including powder milk with live     lactic acid bacteria. October 2001: 34 pages. -   3. Martin R. et al. “Role of commensal and probiotic bacteria in     human health: a focus on inflammatory bowel disease”, Microbial Cell     Factories 2013, 12: 71. -   4. Floch M. H. et al. “Recommendations for probiotic use—201 1     Update”, J. Clin. Gastroenterol. 201 1, 45: S168-S171. -   5. D'Inca R. et al. “Rectal administration of Lactobacillus casei DG     modifies flora composition and Toll-Like receptor expression in     colonic mucosa of patients with mild ulcerative colitis”, Dig. Dis.     Sci. 201 1, 56: 1 178-1 187. -   6. De Souza M. M. et al. “Effects of budesonide and probiotics     enemas on the systemic inflammatory response of rats with     experimental colitis”, Acta Cimrgica Brasileira 2007, 22 (Suppl. 1):     40-45. -   7. Matthes H. et al. “Clinical trial: probiotic treatment of acute     distal ulcerative colitis with rectally administered Escherichia     coli Nissle 1917 (EcN)”, BMC Complementary and Alternative Medicine     2010, 10: 13. -   8. Oliva S. et al. “Randomised clinical trial: the effectiveness of     Lactobacillus Reuteri ATCC 55730 rectal enema in children with     active distal ulcerative colitis”, Aliment. Pharmacol. Ther. 2012,     35: 327-334. -   9. Orlando A. et al. “Clinical implications of mucosal healing in     the management of patients with inflammatory bowel disease”,     Digestive and Liver Disease 2013, 45, 986-991. -   10. Mazzuoli S. et al. “Definition and evaluation of mucosal healing     in clinical practice”, Digestive and Liver Disease 2013, 45,     969-977. -   11. Collins M. N. and Birkinshaw C. “Hyaluronic acid based scaffolds     for tissue engineering—A review”, Carbohydrate Polymers 201 3,     1262-1279. -   12. Necas J. et al. “Hyaluronic acid (hyaluronan): a review”,     Veterinarni Medicina 2008, 53(8): 397-41 1. -   13. Fakhari A. and Berkland C. “Applications and emerging trends of     hyaluronic acid in tissue engineering, as a dermal filler and in     osteoarthritis treatment”, Acta BiomateriaUa 2013, 9, 7081-7092. -   14. Price R. D. et al. “Hyaluronic acid: the scientific and clinical     evidence”, Journal of Plastic, Reconstructive & Aesthetic Surgery     2007, 60: 1110-1 1 19. 

1. A combination comprising a composition containing a probiotic and hyaluronic acid or a pharmaceutically acceptable salt thereof, and an inflammatory bowel disease therapeutic agent selected from the group consisting of 5-ASA, corticosteroids, azathioprine/6-mercaptopurine, methotrexate, cyclosporine, and anti-TNFa agents, wherein the composition is a rectally administered topical composition comprising the probiotic and the hyaluronic acid in an effective amount for treating inflammatory bowel disease, and wherein the hyaluronic acid has a molecular weight ranging from 500,000 to 3,000,000 dalton.
 2. The combination according to claim 1, further comprising at least one physiologically acceptable excipient.
 3. The combination according to claim 1, wherein said probiotic is selected from Lactobacillus acidophilus, Lactobacillus brevis, Lactobacillus buchneri, Lactobacillus casei, Lactobacillus paracasei, Lactobacillus catenaforme, Lactobacillus cellobiosus, Lactobacillus crispatus, Lactobacillus curvatus, Lactobacillus delbrueckii, Lactobacillus fermentum, Lactobacillus jensenii, Lactobacillus leichmannii, Lactobacillus minutus, Lactobacillus plantarum, Lactobacillus reuteri, Lactobacillus rogosae, Lactobacillus salivarius, Bifidobacterium adolescentis, Bifidobacterium angulatum, Bifidobacterium bifidum, Bifidobacterium breve, Bifidobacterium catenulatum, Bifidobacterium dentium, Bifidobacterium eriksonii. Bifidobacterium infants, Bifidobacterium longum, Bifidobacterium plantarum, Bifidobacterium pseudocatenulatum, Bifidobacterium pseudolongum, Streptococcus lactis, Streptococcus raffinolactis, Streptococcus thermophilus, or a mixture thereof.
 4. The combination according to claim 1, wherein the probiotic comprises an amount of living probiotic cells comprised between 200 million and 3 billion.
 5. The combination according to claim 1, wherein the probiotic comprises an amount of living probiotic cells comprised between 0.1 and 3% by weight with respect to the total weight of the composition.
 6. The combination according to claim 1, wherein said hyaluronic acid is a high molecular weight hyaluronic acid greater or equal to 1,000,000 dalton.
 7. The combination according to claim 1, wherein the hyaluronic acid or the pharmaceutically acceptable salt thereof is comprised between 3 and 15% by weight with respect to the total weight of the composition.
 8. The combination according to claim 1, wherein the hyaluronic acid or the pharmaceutically acceptable salt thereof is comprised between 0 mg and 300 mg.
 9. The combination according to claim 1, wherein the probiotic comprises a quantity of living probiotic cells comprised between 0.1 and 3%, and the hyaluronic acid comprised between 3 and 15%, with respect to the total weight of the composition.
 10. (canceled)
 11. (canceled)
 12. The combination according to claim 1, wherein the composition is formulated in the form of a cream, ointment, pomade, solution, suspension, water or gel dispersible powder.
 13. (canceled)
 14. (canceled)
 15. The combination according to claim 1, wherein said probiotic is a Lactobacillus.
 16. The combination according to claim 1, wherein said probiotic is Lactobacillus casei.
 17. The combination of claim 1, wherein the probiotic is a Lactobacillus casei DG deposited at the Pasteur Institute in Paris with the deposit number I-1572CNCM.
 18. The combination according to claim 1 wherein the probiotic comprises an amount of living probiotic cells comprised between 500 million and 2 billion.
 19. The combination according to claim 1 wherein the probiotic comprises an amount of living probiotic cells comprised less than 1% by weight, with respect to the total weight of the composition.
 20. The combination according to claim 1, wherein the hyaluronic acid or the pharmaceutically acceptable salt thereof is comprised about 5% by weight, with respect to the total weight of the composition.
 21. The combination according to claim 1, wherein the hyaluronic acid or the pharmaceutically acceptable salt thereof is comprised between 50 mg and 150 mg.
 22. The combination according to claim 1, wherein the composition is formulated in the form of a water dispersible powder.
 23. A method of treating inflammatory bowel disease comprising rectally administering the combination according to claim 1 to a patient in need thereof.
 24. The method of claim 22 wherein the inflammatory bowel disease is Crohn's disease.
 25. The method of claim 22 wherein the inflammatory bowel disease is ulcerative colitis.
 26. The method of claim 22 wherein the composition is in the form of a cream, an ointment, a pomade, a solution, a suspension, a water dispersible powder or a gel dispersible powder.
 27. The method of claim 22, wherein the composition is in the form of a gel dispersible powder.
 28. The method of claim 22, wherein the composition is administered simultaneously with, separately from, or sequentially with the administration of the inflammatory bowel disease therapeutic agent.
 29. The method of claim 22, wherein said probiotic is a Lactobacillus.
 30. The method of claim 22, wherein the probiotic is a Lactobacillus casei DG deposited at the Pasteur Institute in Paris with the deposit number I-1572CNCM. 